Provider Demographics
NPI:1881029783
Name:INGRAM, LAUREN JETON (FNP)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:JETON
Last Name:INGRAM
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 841656
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-1656
Mailing Address - Country:US
Mailing Address - Phone:903-531-5000
Mailing Address - Fax:
Practice Address - Street 1:113 AIRPORT RD
Practice Address - Street 2:SUITE 301
Practice Address - City:SULPHUR SPRINGS
Practice Address - State:TX
Practice Address - Zip Code:75482-2193
Practice Address - Country:US
Practice Address - Phone:903-439-3285
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-10
Last Update Date:2015-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX803942363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX75-0818167-044OtherTRICARE
TX75-261977-002OtherTRICARE
TX8599NDOtherBCBS
TX75-0818167-015OtherTRICARE
TX75-2616977-028OtherTRICARE
TX8810NFOtherBCBS
TX330574004Medicaid
TX75-0818167-048OtherTRICARE
TX75-1976930-005OtherTRICARE
TXP01290911OtherRAIL ROAD
TXP01291367OtherRAIL ROAD
TX330574003Medicaid
TX75-0818167-022OtherTRICARE
TX75-2616977-001OtherTRICARE
TX330574001Medicaid
TX330574002Medicaid
TX75-1976930-005OtherTRICARE
TX330574003Medicaid
TX330574001Medicaid
TX323403YS6VMedicare PIN